Form 4 - Spouse'S Waiver Of Beneficiary Right To Benefits In A Pension Plan, Locked-In Retirement Account, Life Income Fund Or Annuity Before Payments Start Page 3

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The information I have given in this form is true, to the best of my knowledge, when I sign this

form.

10. I am aware that I am entitled to a copy of this form.

11. I understand that

(a) this form gives only a general description of my legal rights under the Pension Benefits

Standards Act and the regulations under that Act, and

(b) if I wish to understand exactly what my legal rights are, I must read the Pension Benefits

Standards Act and the regulations under that Act and/or seek legal advice.

AIVER

I am signing this waiver to waive or give up the specified right: [Initial one box only]

my right as beneficiary to receive the member’s benefits in the pension plan identified on

this form if the member dies before starting a pension,

my right as beneficiary to receive the former member’s benefits in the locked-in retirement

account or life income fund, identified on this form, after the former member’s death, or

my right as beneficiary to receive the former member’s benefits in the annuity identified on

this form if the former member dies before starting payments from the annuity.

Date [mm/dd/yyyy]

Signed [spouse]

I witnessed this spouse sign this form in

the absence of his or her spouse.

Signed [witness]

Name of witness ...........................................................................................................................................

Address of witness ........................................................................................................................................

OMMENTS AND INSTRUCTIONS

Survivor’s benefits are important and can be valuable. The Pension Benefits Standards Act requires a

specific form for waiving survivor’s benefits to ensure that serious consideration is given to this

decision.

When dealing with valuable assets, obtaining legal advice is usually considered prudent. This form is

not a substitute for legal advice.

This form must be signed and witnessed before the member’s/former member’s death in the absence of

the member/former member, and provided to the plan administrator, locked-in retirement account issuer

or life income fund issuer or the insurance company holding the annuity.

For further information, please contact the plan administrator locked-in retirement account issuer or life

income fund issuer or the insurance company holding the annuity.

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